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Claims work on PHI, with a person making every denial

Health payers, insurers, TPAs, claims administrators. 8 use cases for this industry, 9 more that also apply.

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Where to start

Three to start with

High value for the effort. The risk tier is on each one.

Fraud, waste & abuse patterns

Upcoding, unbundling and outlier providers found in claim history; leads for SIU.

  1. Analyse history
  2. Monitor & alert
Medium riskValue highGuide

Claim validation

Claims checked against coverage, coding rules and documentation. Recommends pay, pend or refer; never denies.

  1. Intake & extract
  2. Validate
High riskValue highGuide

Regulatory change monitoring

New rules and guidance watched; what changes for you summarised with the affected policies.

  1. Monitor & alert
  2. Research
Low riskValue mediumGuide
Use cases

Use cases for Insurance & claims, by department

Customer service 1

Member claim status

Members told where their claim is and what is missing, on the phone, chat or email.

  1. Answer
  2. Converse
High riskValue mediumGuide

Operations 3

Claim validation

Claims checked against coverage, coding rules and documentation. Recommends pay, pend or refer; never denies.

  1. Intake & extract
  2. Validate
High riskValue highGuide

Claim triage

Clean claims fast-tracked, the rest pended or sent to the right adjuster or SIU.

  1. Route
High riskValue mediumGuide

Appeal responses

Appeal letters drafted from the claim, the policy and the medical record, for review.

  1. Intake & extract
  2. Consolidate
  3. Draft
High riskValue mediumGuide

Risk & compliance 4

Regulatory change monitoring

New rules and guidance watched; what changes for you summarised with the affected policies.

  1. Monitor & alert
  2. Research
Low riskValue mediumGuide

Policy Q&A with citations

Staff questions answered from internal policy and procedure, with the section cited.

  1. Answer
Medium riskValue mediumGuide

Fraud, waste & abuse patterns

Upcoding, unbundling and outlier providers found in claim history; leads for SIU.

  1. Analyse history
  2. Monitor & alert
Medium riskValue highGuide

SIU referral drafting

Referral packages drafted from the claim and provider history for the investigator.

  1. Research
  2. Draft
Medium riskValue mediumGuide

Also applies

Use cases from other industries that fit this one too.

Purchasing & suppliers 1

Supplier risk monitoring

Critical suppliers watched continuously for financial, cyber and news risk; alerts with evidence.

  1. Monitor & alert
  2. Research
Medium riskValue mediumGuide

Operations 1

Technology & operations review

Back office, imaging, process flow, vendor contracts and disaster recovery reviewed; bottlenecks and risks found and the report drafted.

  1. Intake & extract
  2. Consolidate
  3. Analyse history
  4. Draft
Medium riskValue highGuide

IT & security 3

Access review certification

Who has access to what, compared with their role; managers asked to confirm or remove.

  1. Consolidate
  2. Validate
  3. Follow up
Medium riskValue highGuide

Change-record reconciliation

Production changes reconciled with approved change records; unapproved changes listed.

  1. Consolidate
Medium riskValue mediumGuide

Security alert triage

Alerts from monitoring tools enriched, de-duplicated and ranked; the likely-real ones escalated with the evidence, the noise closed with a reason.

  1. Intake & extract
  2. Analyse history
  3. Route
Medium riskValue highGuide

Risk & compliance 4

Third-party due-diligence review

Vendor questionnaires and evidence reviewed against the bank's standard; gaps chased with the vendor.

  1. Intake & extract
  2. Validate
  3. Follow up
Medium riskValue highGuide

Issue closure validation

Evidence that an audit or exam issue is fixed checked before the issue is closed.

  1. Validate
Low riskValue mediumGuide

Sanctions screening review

ACH, wire and customer screening tested: lists current, matches handled, alerts cleared with a reason; findings drafted.

  1. Consolidate
  2. Validate
  3. Draft
Medium riskValue highGuide

Regulatory exam preparation

The examiners' request list answered: documents found and checked, owners chased, open findings tracked to closure before the exam starts.

  1. Intake & extract
  2. Validate
  3. Follow up
High riskValue highGuide